Stuart- ACL Reconstruction- Managing the High Risk Patient ......Anterior Cruciate Ligament...

1

ACLReconstructionTipstoPrevent

Failure

MichaelJ. StuartMD

Mayo ClinicRochester, MN

Financial Relationships• Consultant & Royalties- Arthrex

Research Funding• Stryker• USA Hockey Foundation

Off Label Usage• None

Michael J. Stuart MDFebruary 24, 2018

AJSM2014

2

AJSM2014

78 ACL reconstruction patients compared 47 athletes without surgery

• All participated in pivoting/cutting sports

• Followed for injury & athlete exposure (AE) data for a 2 year period

AJSM2014

6x increased risk of a 2nd ACL injury when compared to healthy control participants

30% of athletes suffered a 2nd ACL injury within 24 months of RTS

21% contralateral ACL

9% graft re-tear

AJSM2016

3

90femalesoccer playerscomparedto90femalenon‐soccer players(meanage19.6years)

Graft Failures: 11% vs 1%

Contralateral ACL: 17% vs 4%

AJSM2016

2ndACLtear in…

28%ofallfemalesoccerplayers

34% ofthosewhoreturnedtosoccer

AJSM2016

Tips to Prevent Failure

• Identify all injured structures

• Assess alignment & slope

• Perform meticulous surgery

• Address associated problems

• Focus rehabilitation

• Confirm return-to-play criteria

4

Accurate Diagnosis

Physical Exam• Lachman & dynamic subluxation• varus/valgus stress @ 0 & 30°• posterior sag & drawer• dial test @ 30 & 90°• posterolateral drawer• anteromedial drawer

Accurate DiagnosisRadiographs• AP (standing)• Lateral (full extension)• Merchant• PA flexion (45) Full length standing Lateral tibia standing

MechanicalAxis

5

Weight‐BearingLine

Accurate Diagnosis

MRI• confirm ACL disruption

Accurate Diagnosis

MRI• confirm ACL disruption• meniscus tears

6

MedialMeniscusPosteriorHornRootTear

Accurate Diagnosis

MRI• confirm ACL disruption• meniscus tears• articular cartilage lesions

LateralFemoralCondyleOsteochondral Injury

7

Accurate Diagnosis

MRI• confirm ACL disruption• meniscus tears• articular cartilage lesions• periarticular fractures

Salter‐HarrisType2PhysealFracture

Accurate Diagnosis

MRI• confirm ACL disruption• meniscus tears• articular cartilage lesions• periarticular fractures• associated ligament injuries

8

DistalGrade3MCLSprain

Meticulous Surgical Technique

1. Graft Harvest

2. Notchplasty (as needed)

3. Tunnel Placement

4. Graft Passage

5. Graft Fixation

Stuart et. al. J Knee Surg 25(5) 2012

Technical error is the most common reason for primary ACL reconstruction failure

Femoral tunnel malposition is the most common technical error

9

RationaleforStrategicGraftPlacementinAnteriorCruciateLigamentReconstruction:

I.D.E.A.L. Femoral Tunnel PositionPearle, McAllister, Howell

Isometry

DirectInsertion

Eccentric

Anatomical

Lowtension

RationaleforStrategicGraftPlacementinAnteriorCruciateLigamentReconstruction:

I.D.E.A.L. Femoral Tunnel PositionPearle, McAllister, Howell

anterior (high)

proximal (deep)

within femoral footprint

low tension-flexion pattern

10

• Meniscus repair

• Limb re-alignment

• Other ligament repair/reconstruction

• Articular cartilage restoration

• Tibial slope reduction

• Anterolateral complex reconstruction?

Address Associated Problems

• Repair the meniscus to protect the ACL graft

Root AvulsionBucket Handle

11

18year‐oldmale elitewrestler

• injuredleftkneewhileplayinghighschoolfootball

• jumpedoveropposingplayer&landedwithavalgustwistingforce

• feltapopwithimmediatepainandswelling

• PositiveLachman testonthesidelines

12

LateralMeniscus

RadialTear

LateralMeniscus

13

14

RadialRepair

LateralMeniscus

15

PatellarTendonAutograftACLReconstruction

16

• ResumedDivision1collegiatewrestling

• Nopain,swelling,catching,lockingorgiving‐way

• 5yearfollow‐upexamination&X‐raysplanned

3yearsafterPatellarTendonAutograftACLreconstruction&

ComplexLateralMeniscusRepair

17

Limb Re-alignmentProximal Tibial

Distal Femoral

• EvaluatecoronalplanealignmentonthestandingAP X‐ray

• Obtain a full-length standing (hip to ankle) X-ray if indicated

• Perform a re-alignment osteotomy for mechanical axis >5 varus or valgus

Angle ofCorrection

62% coordinate

Other Ligaments

• Identifyassociatedpatholaxity:

physicalexam

MRI

stressfluoro

18

PCL

FCL

MCL

Superficial MCL

19

Articular Cartilage

• Osteochondral Fixation

• Debridement

• Microfracture

• Osteochondral Autograft

• Osteochondral Allograft

• Cell-based Regeneration

Lateral Femoral Condyle

OsteochondralFracture

Tibial Slope Reduction

1. Tibial slope >13°

2. Anterior tibial translation >10mm

Pre-op Calculation

Deflexion osteotomy indications:

LateralTibiamonopodal standing

20

Anterior Translation12 mm

Monopodal Stance

Posterior Slope25 degrees

Anterior Translation12 mm

Monopodal Stance

Posterior Slope25 degrees

Anterior Translation12 mm

Monopodal Stance

Posterior Slope25 degrees

21

Anterior Translation12 mm

Monopodal Stance

Posterior Slope25 degrees

Anterior Translation0 mm

Monopodal Stance

Posterior Slope7 degrees

• Pain control

• Reduction of swelling/effusion

• Range of motion (terminal extension)

• Strength

• Proprioception

• Sport-specific activities

Focus Rehabilitation

“Decreased neuromuscular control & high-risk movement biomechanics, which appear to be heavily influenced by abnormal trunk & lower extremity movement patterns, not only predict first knee injury risk but also re-injury risk.”

22

• Qualitative assessment of movement patterns

• Serial strength & functional testing to identify neuromuscular strategies

• Rehabilitation protocols targeted to eliminate limb asymmetries

Confirm Return-to-Play Criteria

ACL Reconstruction:Tips to Optimize Outcome

• Assess alignment & slope

• Identify all injured structures

• Perform Meticulous Surgery

• Address Associated Problems

• Focus Rehabilitation

• Confirm Return-to-Play Criteria

ThankYou